Regular i.v. therapy?

Question

Hello,
my son is 6 years old and has the Pseudomonas already for about 4 years. In the year 2012, 2 i.v. therapies had been done, as he did not well either. This year he has stayed free of infections and has no restrictions. The Pseudomonas has not beed detected anymore in the throat swab, either. For control reasons, the antibody titer has again been tested. This is however higher than before the i.v. therapies last year. Now we got differing statements concerning the i.v. therapy. We have been told, that the Pseudmonas is chronic and the i.v. courses have to be repeated regularly. Another time we have been told, that we will wait, as he is doing well at the moment. What is better? Furthermore, I would like to know which investigations would make sense? My son has never had a CT or MRI, only normal x-ray investigations. I have heard several times that this would be standard.
I would be very glad about an answer.
Yours sincerely,

Answer

Hello,
You describe that your son (6y) with CF has a chronic infection/colonization with Pseudomonas aeruginosa. In case of worsening of the illness in spite of a regular performed suppressive therapy with inhalative antibiotics, an i.v. antibiotic therapy is indeed indicated. Obviously this therapy was successfull and stabilized the course of the illness (comparison of 2012 and 2013). Indeed, the success of a therapy or a judgement of the status of the lung is not so easy. A lung function is inhere not sufficient. There are centers, that do regular CT/MRI investigations and in case of an unclear course, also a bronchoscopy. On the CT/MRI one can see the CF typical bronchiectasis in the lung much better than in the thorax x-ray and can therefore make better statements about the course. If applicable, one would intensify therapy e.g. concerning the inhalations. On the other side one has also to consider the risks (e.g. radiation exposure) of these investigations.
Nevertheless I think, that we have to have a very close look in order to be able to judge a therapy and its success.

The question about regular i.v. therapies is very difficult. An acutal German guidelines has just been published ("Lung disease in CF", module 1: diagnostics and therapy after the first finding of Pseudomonas aeruginosa). In case of a chronic infection, things look different. There is no uniform opinion about regular i.v. therapies, only different recommendations, and it stays often an individual decision. A worsening of the health status (more cough, more sputum, less apetite, weight loss, etc) leads however in most cases to an antibiotic therapy, if other causes could have been excluded. Besides a Pseudomonas effective antibiotic long-term therapy with an available antibiotic (aztreonamlysine, colistin, tobramycin) the visitis at you CF-center are very important. As only by this way deteriorations can be realized quickly and treated in time. Here the data is clear: the less exacerbations (worsening of the situation) the better for the patient. Please talk to your center about a long-term therapy with azithromycin.

Yours sincerely,
Dr. O. Eickmeier

11.12.2013